Mechanisms for Integrating Real Data into Search Game Simulations: An Application to Winter Health Service Pressures and Preventative Policies.

While modelling and simulation are powerful techniques for exploring complex phenomena, if they are not coupled with suitable real-world data any results obtained are likely to require extensive validation. We consider this problem in the context of search game modelling, and suggest that both demographic and behaviour data are used to configure certain model parameters. We show this integration in practice by using a combined dataset of over 150,000 individuals to configure a specific search game model that captures the environment, population, interventions and individual behaviours relating to winter health service pressures. The presence of this data enables us to more accurately explore the potential impact of service pressure interventions, which we do across 33,000 simulations using a computational version of the model. We find government advice to be the best-performing intervention in simulation, in respect of improved health, reduced health inequalities, and thus reduced pressure on health service utilisation.

Access to adolescent sexual and reproductive health services in Accra, Ghana: An exploratory qualitative study.

Nearly 31% of the Ghanaian population are adolescents, and these populations persistently face high rates of teenage pregnancies and unsafe abortions. This is despite sexual and reproductive health (SRH) being taught in the school curriculum. In this qualitative study, we explore the factors affecting adolescents' access to, and experiences of, SRH services in Accra, Ghana. We conducted 12 focus group discussions (FGDs) with adolescents and 13 key informant interviews (KIs) in Ghana. The FGDs were conducted with school-going and out-of-school adolescents. KIIs were conducted with various stakeholders working with adolescents or in SRH services. All interviews were conducted in English, audio recorded and transcribed verbatim. We applied the Dahlgren-Whitehead Rainbow model of health determinants and used a thematic analysis. Eight themes were identified, across micro, meso and macro levels, that influence adolescents' SRH access and experience in Accra. These included: family, social networks, the role of schools, health providers and services, the policy landscape, gender norms, cultural norms, and poverty. The findings highlight several factors that influence adolescents' access to appropriate SRH services in this context and demonstrate the need for a multisectoral effort to address structural factors such as harmful gender norms and persistent poverty.

A qualitative study examining the health system's response to COVID-19 in Sierra Leone.

The paper examines the health system's response to COVID-19 in Sierra Leone. It aims to explore how the pandemic affected service delivery, health workers, patient access to services, leadership, and governance. It also examines to what extent the legacy of the 2013-16 Ebola outbreak influenced the COVID-19 response and public perception. Using the WHO Health System Building Blocks Framework, we conducted a qualitative study in Sierra Leone where semi-structured interviews were conducted with health workers, policymakers, and patients between Oct-Dec 2020. We applied thematic analysis using both deductive and inductive approaches. Twelve themes emerged from the analysis: nine on the WHO building blocks, two on patients' experiences, and one on Ebola. We found that routine services were impacted by enhanced infection prevention control measures. Health workers faced additional responsibilities and training needs. Communication and decision-making within facilities were reported to be coordinated and effective, although updates cascading from the national level to facilities were lacking. In contrast with previous health emergencies which were heavily influenced by international organisations, we found that the COVID-19 response was led by the national leadership. Experiences of Ebola resulted in less fear of COVID-19 and a greater understanding of public health measures. However, these measures also negatively affected patients' livelihoods and their willingness to visit facilities. We conclude, it is important to address existing challenges in the health system such as resources that affect the capacity of health systems to respond to emergencies. Prioritising the well-being of health workers and the continued provision of essential routine health services is important. The socio-economic impact of public health measures on the population needs to be considered before measures are implemented.

A step closer towards achieving universal health coverage: the role of gender in enrolment in health insurance in India.

BACKGROUND: There is limited understanding of how universal health coverage (UHC) schemes such as publicly-funded health insurance (PFHI) benefit women as compared to men. Many of these schemes are gender-neutral in design but given the existing gender inequalities in many societies, their benefits may not be similar for women and men. We contribute to the evidence by conducting a gender analysis of the enrolment of individuals and households in India's national PFHI scheme, Rashtriya Swasthya Bima Yojana (RSBY). METHODS: We used data from a cross-sectional household survey on RSBY eligible families across eight Indian states and studied different outcome variables at both the individual and household levels to compare enrolment among women and men. We applied multivariate logistic regressions and controlled for several demographic and socio-economic characteristics. RESULTS: At the individual level, the analysis revealed no substantial differences in enrolment between men and women. Only in one state were women more likely to be enrolled in RSBY than men (AOR: 2.66, 95% CI: 1.32-5.38), and this pattern was linked to their status in the household. At the household level, analyses revealed that female-headed households had a higher likelihood to be enrolled (AOR: 1.36, 95% CI: 1.14-1.62), but not necessarily to have all household members enrolled. CONCLUSION: Findings are surprising in light of India's well-documented gender bias, permeating different aspects of society, and are most likely an indication of success in designing a policy that did not favour participation by men above women, by mandating spouse enrolment and securing enrolment of up to five family members. Higher enrolment rates among female-headed households are also an indication of women's preferences for investments in health, in the context of a conducive policy environment. Further analyses are needed to examine if once enrolled, women also make use of the scheme benefits to the same extent as men do. India is called upon to capitalise on the achievements of RSBY and apply them to newer schemes such as PM-JAY.

Adjustments in purchasing arrangements to support the COVID-19 health sector response: evidence from eight middle-income countries.

The COVID-19 pandemic has triggered several changes in countries' health purchasing arrangements to accompany the adjustments in service delivery in order to meet the urgent and additional demands for COVID-19-related services. However, evidence on how these adjustments have played out in low- and middle-income countries is scarce. This paper provides a synthesis of a multi-country study of the adjustments in purchasing arrangements for the COVID-19 health sector response in eight middle-income countries (Armenia, Cameroon, Ghana, Kenya, Nigeria, Philippines, Romania and Ukraine). We use secondary data assembled by country teams, as well as applied thematic analysis to examine the adjustments made to funding arrangements, benefits packages, provider payments, contracting, information management systems and governance arrangements as well as related implementation challenges. Our findings show that all countries in the study adjusted their health purchasing arrangements to varying degrees. While the majority of countries expanded their benefit packages and several adjusted payment methods to provide selected COVID-19 services, only half could provide these services free of charge. Many countries also streamlined their processes for contracting and accrediting health providers, thereby reducing administrative hurdles. In conclusion, it was important for the countries to adjust their health purchasing arrangements so that they could adequately respond to the COVID-19 pandemic, but in some countries financing challenges resulted in issues with equity and access. However, it is uncertain whether these adjustments can and will be sustained over time, even where they have potential to contribute to making purchasing more strategic to improve efficiency, quality and equitable access in the long run.

Determinants of lipid clinic referral and attendance in a multi-ethnic adult population in south London: a cross-sectional study.

BACKGROUND: Primary dyslipidaemias, including familial hypercholesterolaemia, are underdiagnosed genetic disorders that substantially increase risk for premature coronary artery disease in adults. Early identification of primary dyslipidaemias via lipid clinic referral optimises patient management and enables cascade screening of relatives. Improving the identification of primary dyslipidaemias, and understanding disparities in ascertainment and management, is an NHS priority. We aimed to assess determinants of lipid clinic referral or attendance (LCR) in ethnically diverse adults. METHODS: We did a retrospective cross-sectional study using the Lambeth DataNet containing anonymised data from 41 general practitioner (GP) practices in south London. We looked at referral data for adult patients aged 18 years and older from Jan 1, 1995, until May 14, 2018. LCR was the main outcome. We used sequential multilevel logistic regression models adjusted for practice effects to estimate the odds of LCR assessed across six ethnic groups (reference group White) and patient-level factors (demographic, socioeconomic, lifestyle, comorbidities, total cholesterol [TC] >7·5mmol/L, statin prescription, and practice factors). The study was approved by NHS South East London Clinical Commissioning Group (CCG) and NHS Lambeth CCG. FINDINGS: 780 (0·23%) of 332 357 adult patients were coded as referred (n=538) or seen (n=252) in a lipid clinic. 164 487 (46·49%) were women (appendix). The fully adjusted model for odds of LCR showed the following significant associations for age (odds ratio [OR] 0·96, 95% CI 0·96-0·97, p<0·001); Black, African, Caribbean, or Black-British ethnicity (0·67, 0·53-0·84, p=0·001); ex-smoker status (1·29, 1·05-1·57, p=0·014); TC higher than 7·5 mmol/L (12·18, 9·60-15·45, p<0·001); statin prescription (14·01, 10·85-18·10, p<0·001); diabetes (0·72, 0·58-0·91, p=0·005); high-frequency GP attendance at seven or more GP consultations in the past year (1·49, 1·21-1·84, p<0·001); high GP-density (0·5-0·99 full-time equivalent GPs per 1000 patients; 2·70, 1·23-5·92, p=0·013). Sensitivity analyses for LCR restricted to familial hypercholesterolaemia-coded patients (n=581) found associations with TC higher than 7·5 mmol/L (4·26, 1·89-9·62, p<0·001), statin prescription (16·96, 2·19-131·36, p=0·007), and high GP-density (5·73, 1·27-25·93, p=0·023), with no significant associations with ethnicity. The relative contribution of GP practices to LCR was 6·32% of the total variance. There were no significant interactions between ethnicity and deprivation, age, or obesity. INTERPRETATION: While interpretation is limited by the accuracy and completeness of coded records, the study showed factors associated with a higher likelihood of LCR included individuals recorded as having TC higher than 7·5 mmol/L, statin prescription, ex-smoker status, high-frequency GP attendance, and registration at a GP practice with 0·5-0·99 GP density. Patients with increasing age; Black, African, Caribbean, or Black-British ethnicity patients; and patients with diabetes had lower odds of LCR. Finally, the difference in odds of LCR between Black and White patients highlights potential health inequalities. FUNDING: NHS Race & Health Observatory.

Effects of the Indian National Health Insurance Scheme (PM-JAY) on Hospitalizations, Out-of-pocket Expenditures and Catastrophic Expenditures.

India launched one of the world's largest health insurance programs, the Pradhan Mantri Jan Arogya Yojana (PM-JAY), targeting more than 500 million economically and socially disadvantaged Indians. PM-JAY is publicly funded and covers hospitalization costs in public and private facilities. We examine how PM-JAY has affected hospitalizations and out-of-pocket expenditures (OOPE), and given the high use of private health care in India, we compare these outcomes across public and private facilities. We conducted a household survey to collect data on socioeconomic and demographic information, health status and hospitalizations for more than 57,000 PM-JAY eligible individuals in six Indian states. Using multivariate regression models, we estimated whether PM-JAY was associated with any changes in hospitalizations, OOPE and catastrophic health expenditures (CHE) and whether these differed across public and private facilities. We found that PM-JAY was not associated with an increase in hospitalizations, but it increased the probability of visiting a private facility by 4.6% points (p < .05). PM-JAY was associated with a relative reduction of 13% in OOPE (p < .1) and 21% in CHE (p < .01). This was entirely driven by private facilities, where relative OOPE was reduced by 17% (p < .01) and CHE by 19% (p < .01). This implied that PM-JAY has shifted use from public to private hospitalizations. Given the complex healthcare system with the presence of parallel public and private systems in India, our study concludes that for economically and socially disadvantaged groups, PM-JAY contributes to improved access to secondary and tertiary care services from private providers.

Awareness of India's national health insurance scheme (PM-JAY): a cross-sectional study across six states.

The literature suggests that a first barrier towards accessing benefits of health insurance in low- and middle-income countries is lack of awareness of one's benefits. Yet, across settings and emerging schemes, limited scientific evidence is available on levels of awareness and their determinants. To fill this gap, we assessed socio-demographic and economic determinants of beneficiaries' awareness of the Pradhan Mantri Jan Arogya Yojana (PM-JAY), the national health insurance scheme launched in India in 2018, and their awareness of own eligibility. We relied on cross-sectional household (HH) survey data collected in six Indian states between 2019 and 2020. Representative data of HHs eligible for PM-JAY from 11 618 respondents (an adult representative from each surveyed HH) were used. We used descriptive statistics and multivariable logistic regression models to explore the association between awareness of PM-JAY and of one's own eligibility and socio-economic and demographic characteristics. About 62% of respondents were aware of PM-JAY, and among the aware, 78% knew that they were eligible for the scheme. Regression analysis confirmed that older respondents with a higher educational level and salaried jobs were more likely to know about PM-JAY. Awareness was lower among respondents from Meghalaya and Tamil Nadu. Respondents from Other Backward Classes, of wealthier socio-economic status or from Meghalaya or Gujarat were more likely to be aware of their eligibility status. Respondents from Chhattisgarh were less likely to know about their eligibility. Our study confirms that while more than half of the eligible population was aware of PM-JAY, considerable efforts are needed to achieve universal awareness. Socio-economic gradients confirm that the more marginalized are still less aware. We recommend implementing tailored, state-specific information dissemination approaches focusing on knowledge of specific scheme features to empower beneficiaries to demand their entitled services.

Strengthening ethics committees for health-related research in sub-Saharan Africa: a scoping review.

OBJECTIVE: Health-related research in sub-Saharan Africa (SSA) has grown over the years. However, concerns have been raised about the state of research ethics committees (RECs). This scoping review examines the literature on RECs for health-related research in SSA and identifies strategies that have been applied to strengthen the RECs. It focuses on three aspects of RECs: regulatory governance and leadership, administrative and financial capacity and technical capacity of members. DESIGN: A scoping review of published literature, including grey literature, was conducted using the Joanna Briggs Institute approach. DATA SOURCES: BioOne, CINAHL, Embase (via Ovid), Education Abstracts, Global Health, Google Scholar, Jstor, OpenEdition (French), Philosopher's Index, PsycINFO, PubMed, Science Citation and Expanded Index (Web of Science), reference lists of included studies and specific grey literature sources. ELIGIBILITY CRITERIA: We included empirical studies on RECs for health-related research in SSA, covering topics on REC leadership and governance, administrative and financial capacity and the technical capacity of REC members. We included studies published between 01 January 2000 and 18 February 2022 and written in English, French, Portuguese or Swahili. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers screened the records. Data were extracted by one reviewer and cross-checked by another. Owing to the heterogeneity of included studies, thematic analysis was used. RESULTS: We included 54 studies. The findings show that most RECs in SSA work under significant administrative and financial constraints, with few opportunities for capacity building for committee members. This has an impact on the quality of reviews and the overall performance of RECs. Although most countries have national governance systems for RECs, they lack regulations on accountability, transparency and monitoring of RECs. CONCLUSIONS: This review provides a comprehensive overview of the literature on RECs for health-related research in SSA and contributes to our understanding of how RECs can be strengthened.

The impact of the COVID-19 pandemic on hospital utilisation in Sierra Leone.

INTRODUCTION: The COVID-19 pandemic has adversely affected health systems in many countries, but little is known about effects on health systems in sub-Saharan Africa. This study examines the effects of COVID-19 on hospital utilisation in a sub-Saharan country, Sierra Leone. METHODS: Mixed-methods study using longitudinal nationwide hospital data (admissions, operations, deliveries and referrals) and qualitative interviews with healthcare workers and patients. Hospital data were compared across quarters (Q) in 2020, with day 1 of Q2 representing the start of the pandemic in Sierra Leone. Admissions are reported in total and disaggregated by sex, service (surgical, medical, maternity and paediatric) and hospital type (government or private non-profit). Referrals in 2020 were compared with 2019 to assess whether any changes were the result of seasonality. Comparisons were performed using Student's t-test. Qualitative data were analysed using thematic analysis. RESULTS: From Q1 to Q2, weekly mean hospital admissions decreased by 14.7% (p=0.005). Larger decreases were seen in male 18.8% than female 12.5% admissions. The largest decreases were in surgical admissions, a 49.8% decrease (p<0.001) and medical admissions, a 28.7% decrease (p=0.002). Paediatric and maternity admissions did not significantly change. Total operations decreased by 13.9% (p<0.001), while caesarean sections and facility-based deliveries showed significant increases: 12.7% (p=0.014) and 7.5% (p=0.03), respectively. In Q3, total admissions remained 13.2% lower (p<0.001) than Q1. Mean weekly referrals were lower in Q2 and Q3 of 2020 compared with 2019, suggesting findings were unlikely to be seasonal. Qualitative analysis identified both supply-side factors, prioritisation of essential services, introduction of COVID-19 services and pausing elective care, and demand-side factors, fear of nosocomial infection and financial hardship. CONCLUSION: The study demonstrated a decrease in hospital utilisation during COVID-19, the decrease is less than reported in other countries during COVID-19 and less than reported during the Ebola epidemic.

Modern contraceptive use among women in need of family planning in India: an analysis of the inequalities related to the mix of methods used.

OBJECTIVE: To evaluate the type of contraceptives used by women in need of family planning in India and the inequalities associated with that use according to women's age, education, wealth, subnational region of residence and empowerment level. METHODS: Using data from the Indian National Family and Health Survey-4 (2015-2016), we evaluated the proportion of partnered women aged 15-49 years with demand for family planning satisfied (DFPS) with modern contraceptive methods. We also explored the share of each type of contraception [short- (e.g., condom, pill) and long-acting (i.e., IUD) reversible contraceptives and permanent methods] and related inequalities. RESULTS: The majority (71.8%; 95% CI 71.4-72.2) of women in need of contraception were using a modern method, most (76.1%) in the form of female sterilization. Condom and contraceptive pill were the second and third most frequently used methods (11.8% and 8.5%, respectively); only 3.2% reported IUD. There was a nearly linear exchange from short-acting to permanent contraceptive methods as women aged. Women in the poorest wealth quintile had DFPS with modern methods at least 10 percentage points lower than other women. We observed wide geographic variation in DFPS with modern contraceptives, ranging from 23.6% (95% CI 22.1-25.2) in Manipur to 93.6% (95% CI 92.8-94.3) in Andhra Pradesh. Women with more accepting attitudes towards domestic violence and lower levels of social independence had higher DFPS with modern methods but also had higher reliance on permanent methods. Among sterilized women, 43.2% (95% CI 42.7-43.7) were sterilized before age 25, 61.5% (95% CI 61.0-62.1) received monetary compensation for sterilization, and 20.8% (95% CI 20.3-21.3) were not informed that sterilization prevented future pregnancies. CONCLUSION: Indian family planning policy should prioritize women-centered care, making reversible contraceptive methods widely available and promoted.

Ensuring universal access to sexual and reproductive health and reproductive rights for all women is one of the Sustainable Development Goals, promoted by the United Nations and adopted by 193 countries, including India. To address women's need for contraception, the provision of a wide range of safe, effective and affordable contraceptive methods is essential. In this study, we evaluated the type of contraceptives used by women in need of contraception in India and the inequalities in contraceptive use among different subgroups of women. The majority (71.8%) of women in need of contraception were using a modern method, most (76.1%) in the form of female sterilization. Condom and contraceptive pill were the second and third most frequently used methods (11.8% and 8.5%, respectively); only 3.2% reported IUD. We observed an exchange from short-acting to permanent contraceptive methods as women aged. The poorest women presented demand for family planning satisfied (DFPS) with modern methods at least 10 percentage points lower than other women. There was wide geographic variation in DFPS with modern contraceptives, ranging from 23.6% in Manipur to 93.6% in Andhra Pradesh. Women with more accepting attitudes towards domestic violence and lower levels of social independence had higher DFPS with modern methods but also had higher reliance on permanent methods. Among sterilized women, 43.2% were sterilized before age 25, 61.5% received monetary compensation for sterilization, and 20.8% were not informed that sterilization prevented future pregnancies. Indian family planning policy should prioritize women-centered care, making reversible contraceptive methods widely available and promoted.

Strengthening ethics committees for health-related research in sub-Saharan Africa: a scoping review protocol.

INTRODUCTION: Health research in low-income and middle-income countries, which face the greatest burden of disease, is a vital component of efforts to combat global health inequality. With increased research, there has also been concern about ethical and regulatory issues and the state of research ethics committees, with various attempts to strengthen them. This scoping review examines the literature on ethics committees for health-related research in sub-Saharan Africa, with a focus on regulatory governance and leadership, administrative and financial capacity, and conduct of ethical reviews. METHODS AND ANALYSIS: We will use the methodological approach proposed by Arksey and O'Malley and adapted by Levac et al and the Joanna Briggs Institute. Inclusion and exclusion criteria are based on the 'Population-Concept-Context' framework. Literature (from January 2000 to December 2020) will be searched in multiple databases including Embase and PubMed and websites of relevant organisations. All records will be screened by applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Review flowchart: two reviewers will independently screen titles and abstracts, and full text of included records. Using an inductive approach, we will synthesise the literature, identify best practice and gaps in evidence on strengthening research ethics committees. ETHICS AND DISSEMINATION: Ethical approval is not required as the review will include only published literature. The findings will be published in a peer-reviewed journal and presented at stakeholder meetings and conferences.

Mixed and Multi-Methods Protocol to Evaluate Implementation Processes and Early Effects of the Pradhan Mantri Jan Arogya Yojana Scheme in Seven Indian States.

In September 2018, India launched Pradhan Mantri Jan Arogya Yojana (PM-JAY), a nationally implemented government-funded health insurance scheme to improve access to quality inpatient care, increase financial protection, and reduce unmet need for the most vulnerable population groups. This protocol describes the methodology adopted to evaluate implementation processes and early effects of PM-JAY in seven Indian states. The study adopts a mixed and multi-methods concurrent triangulation design including three components: 1. demand-side household study, including a structured survey and qualitative elements, to quantify and understand PM-JAY reach and its effect on insurance awareness, health service utilization, and financial protection; 2. supply-side hospital-based survey encompassing both quantitative and qualitative elements to assess the effect of PM-JAY on quality of service delivery and to explore healthcare providers' experiences with scheme implementation; and 3. process documentation to examine implementation processes in selected states transitioning from either no or prior health insurance to PM-JAY. Descriptive statistics and quasi-experimental methods will be used to analyze quantitative data, while thematic analysis will be used to analyze qualitative data. The study design presented represents the first effort to jointly evaluate implementation processes and early effects of the largest government-funded health insurance scheme ever launched in India.

Household air pollution and arthritis in low-and middle-income countries: Cross-sectional evidence from the World Health Organization's study on Global Ageing and Adult Health.

BACKGROUND: Evidence points to a clear link between air pollution exposure and several chronic diseases though investigations regarding arthritis are still lacking. Emerging evidence suggests an association between ambient air pollution and rheumatoid arthritis. Household air pollution exposure, conversely, is largely unstudied but may be an important consideration for arthritis, particularly in low- and middle-income countries (LMICs), where cooking and heating activities can generate high indoor air pollutant levels. METHODS: We investigated the association of household air pollution (electricity vs. gas; kerosene/paraffin; coal/charcoal; wood; or agriculture/crop/animal dung/shrubs/grass as the main fuel used for cooking) and arthritis in six LMICs (China, Ghana, India, Mexico, the Russian Federation, South Africa) using data from Wave I of the World Health Organization Study on Global AGEing and Adult Health (SAGE) (2007-2010). Multivariable analyses were adjusted for sociodemographic, household and lifestyle characteristics and several comorbidities. RESULTS: The use of gas (aOR = 1.76, 95%CI: 1.40-2.21); coal (aOR = 1.74, 95%CI: 1.22-2.47); wood (aOR = 1.69, 95%CI: 1.30-2.19); or agriculture/crop/animal dung/shrubs/grass: aOR = 1.95 (1.46-2.61) fuels for cooking were strongly associated with an increased odds of arthritis, compared to electricity in cluster and stratified adjusted analyses. Gender (female), age (≥50 years), overweight (25.0 ≤BMI<30.0 kg/m2), obesity (BMI ≥30.0 kg/m2), former and current alcohol consumption, and the comorbidities angina pectoris, diabetes, chronic lung disease, depression and hypertension were also associated with a higher odds of arthritis. Underweight (BMI<18.5 kg/m2) and higher education levels (college/university completed/post-graduate studies) were associated with a lower odds of arthritis. CONCLUSIONS: These findings suggest that exposure to household air pollution from cook fuels is associated with an increased odds of arthritis in these regions, which warrants further investigation.

How do supply- and demand-side interventions influence equity in healthcare utilisation? Evidence from maternal healthcare in Senegal.

The launch of the Millennium Development Goals in 2000, followed by the Sustainable Development Goals in 2015, and the increasing focus on achieving universal health coverage has led to numerous interventions on both supply- and demand-sides of health systems in low- and middle-income countries. While tremendous progress has been achieved, inequities in access to healthcare persist, leading to calls for a closer examination of the equity implications of these interventions. This paper examines the equity implications of two such interventions in the context of maternal healthcare in Senegal. The first intervention on the supply-side focuses on improving the availability of maternal health services while the second intervention, on the demand-side, abolished user fees for facility deliveries. Using three rounds of Demographic Health Surveys covering the period 1992 to 2010 and employing three measures of socioeconomic status (SES) based on household wealth, mothers' education and rural/urban residence - we find that although both interventions increase utilisation of maternal health services, the rich benefit more from the supply-side intervention, thereby increasing inequity, while those living in poverty benefit more from the demand-side intervention i.e. reducing inequity. Both interventions positively influence facility deliveries in rural areas although the increase in facility deliveries after the demand-side intervention is more than the increase after the supply-side intervention. There is no significant difference in utilisation based on mothers' education. Since people from different SES categories are likely to respond differently to interventions on the supply- and demand-side of the health system, policymakers involved in the design of health programmes should pay closer attention to concerns of inequity and elite capture that may unintentionally result from these interventions.

Midwives' perspectives on (dis)respectful intrapartum care during facility-based delivery in sub-Saharan Africa: a qualitative systematic review and meta-synthesis.

BACKGROUND: In the past decade, the negative impact of disrespectful maternity care on women's utilisation and experiences of facility-based delivery has been well documented. Less is known about midwives' perspectives on these labour ward dynamics. Yet efforts to provide care that satisfies women's psycho-socio-cultural needs rest on midwives' capacity and willingness to provide it. We performed a systematic review of the emerging literature documenting midwives' perspectives to explore the broader drivers of (dis)respectful care during facility-based delivery in the sub-Saharan African context. METHODS: Seven databases (CINAHL, PsychINFO, PsychArticles, Embase, Global Health, Maternity and Infant Care and PubMed) were systematically searched from 1990 to May 2018. Primary qualitative studies with a substantial focus on the interpersonal aspects of care were eligible if they captured midwives' voices and perspectives. Study quality was independently assessed by two reviewers and PRISMA guidelines were followed. The results and findings from each study were synthesised using an existing conceptual framework of the drivers of disrespectful care. RESULTS: Eleven papers from six countries were included and six main themes were identified. 'Power and control' and 'Maintaining midwives' status' reflected midwives' focus on the micro-level interactions of the mother-midwife dyad. Meso-level drivers of disrespectful care were: the constraints of the 'Work environment and resources'; concerns about 'Midwives' position in the health systems hierarchy'; and the impact of 'Midwives' conceptualisations of respectful maternity care'. An emerging theme outlined the 'Impact on midwives' of (dis)respectful care. CONCLUSION: We used a theoretically informed conceptual framework to move beyond the micro-level and interrogate the social, cultural and historical factors that underpin (dis)respectful care. Controlling women was a key theme, echoing women's experiences, but midwives paid less attention to the social inequalities that distress women. The synthesis highlighted midwives' low status in the health system hierarchy, while organisational cultures of blame and a lack of consideration for them as professionals effectively constitute disrespect and abuse of these health workers. Broader, interdisciplinary perspectives on the wider drivers of midwives' disrespectful attitudes and behaviours are crucial if efforts to improve the maternity care environment - for women and midwives - are to succeed.

Impact of an employment guarantee scheme on utilisation of maternal healthcare services: Results from a natural experiment in India.

We assess the impact of India's National Rural Employment Guarantee (NREG) scheme, the world's largest workfare scheme, on healthcare utilisation - specifically maternal healthcare. The primary objective of NREG is to improve the income of rural households by guaranteeing 100 days of employment. We expect that by improving household income, thereby reducing some of the financial barriers, such as out-of-pocket payments, NREG can increase utilisation of maternal health services. Using a nationally representative household survey and a difference-in-differences approach that exploits the phased rollout of the scheme, we estimate the impact of NREG on utilisation of maternal health services: mainly deliveries at health facilities. We find that NREG did not increase overall facility deliveries, even though it led to an increase in deliveries at public facilities. There is weak evidence to suggest that deliveries at private facilities reduced due to NREG. Furthermore, sub-group analyses reveal that among poorer households, who are more likely to participate in NREG, there is a reduction in facility deliveries while home deliveries increased. Among richer households, NREG increased deliveries at public facilities. There was no impact on households belonging to marginalised castes. We conclude by discussing the possible mechanisms for these effects and its impact on equity in healthcare utilisation.

Treatment of tuberculosis in complex emergencies in developing countries: a scoping review.

Almost 172 million people live in complex emergencies globally resulting from political and/or economic instability. The provision and continuity of health care in complex emergencies remain a significant challenge. Health agencies are often hesitant to implement tuberculosis programmes in particular because its treatment requires a longer commitment than most acute diseases. However, not treating tuberculosis promptly increases mortality and untreated tuberculosis further increases the incidence of tuberculosis. Given that complex emergencies are increasing globally, there is an urgent need to analyse the available evidence to improve our understanding of how best to deliver tuberculosis programmes in such settings. Using a scoping review method, we selected and analysed 15 studies on tuberculosis programmes in complex emergencies. We found that despite the challenges, tuberculosis programmes have been successful in complex emergencies. We identified seven cross-cutting factors that were found to be important: service providers and treatment regime, training and supervision, donor support, adherence, leadership and coordination, monitoring and government and community support. In general, programmes showed greater creativity and flexibility to adapt to the local conditions and at times, it also meant diverting from the WHO guidelines. We identify areas of further research including the need to study the effectiveness of programmes that divert from the WHO guidelines and their implication on drug resistance.

Equitable access to health insurance for socially excluded children? The case of the National Health Insurance Scheme (NHIS) in Ghana.

To help reduce child mortality and reach universal health coverage, Ghana extended free membership of the National Health Insurance Scheme (NHIS) to children (under-18s) in 2008. However, despite the introduction of premium waivers, a substantial proportion of children remain uninsured. Thus far, few studies have explored why enrolment of children in NHIS may remain low, despite the absence of significant financial barriers to membership. In this paper we therefore look beyond economic explanations of access to health insurance to explore additional wider determinants of enrolment in the NHIS. In particular, we investigate whether social exclusion, as measured through a sociocultural, political and economic lens, can explain poor enrolment rates of children. Data were collected from a cross-sectional survey of 4050 representative households conducted in Ghana in 2012. Household indices were created to measure sociocultural, political and economic exclusion, and logistic regressions were conducted to study determinants of enrolment at the individual and household levels. Our results indicate that socioculturally, economically and politically excluded children are less likely to enrol in the NHIS. Furthermore, households excluded in all dimensions were more likely to be non-enrolled or partially-enrolled (i.e. not all children enrolled within the household) than fully-enrolled. These results suggest that equity in access for socially excluded children has not yet been achieved. Efforts should be taken to improve coverage by removing the remaining small, annually renewable registration fee, implementing and publicising the new clause that de-links premium waivers from parental membership, establishing additional scheme administrative offices in remote areas, holding regular registration sessions in schools and conducting outreach sessions and providing registration support to female guardians of children. Ensuring equitable access to NHIS will contribute substantially to improving child health and reducing child mortality in Ghana.

Cost of abortions in Zambia: A comparison of safe abortion and post abortion care.

Unsafe abortion is a significant but preventable cause of maternal mortality. Although induced abortion has been legal in Zambia since 1972, many women still face logistical, financial, social, and legal obstacles to access safe abortion services, and undergo unsafe abortion instead. This study provides the first estimates of costs of post abortion care (PAC) after an unsafe abortion and the cost of safe abortion in Zambia. In the absence of routinely collected data on abortions, we used multiple data sources: key informant interviews, medical records and hospital logbooks. We estimated the costs of providing safe abortion and PAC services at the University Teaching Hospital, Lusaka and then projected these costs to generate indicative cost estimates for Zambia. Due to unavailability of data on the actual number of safe abortions and PAC cases in Zambia, we used estimates from previous studies and from other similar countries, and checked the robustness of our estimates with sensitivity analyses. We found that PAC following an unsafe abortion can cost 2.5 times more than safe abortion care. The Zambian health system could save as much as US$0.4 million annually if those women currently treated for an unsafe abortion instead had a safe abortion.